What is placenta accreta?
villi of placenta attach to myometrium, not to desidua basalis
What is placenta increta?
placental villi invade myometrium
increta = invades
What is placenta percreta?
placental villi penetrate through myometrium, may reach bladder
percreta = penetrates
Why is placenta accreta, increta or percreta an issue?
deep penetration -> poor separation/retention -> hemorrhage, risk of infection
Tx for retained placental tissue?
#1. manage blood loss: 2 large bore IV, type and screen (45 mins)
reminder: type = blood type, ABO antigens & RhD antigen
screen = "unexpected" antibodies, especially in patients with multiple transfusions
*type and screen only valid for 3 months post delivery, as moms can make new antibodies to fetal antigens during delivery
#2. Brant maneuver - get placenta out by holding on to uterus via pressure on suprapubic area (to avoid inversion) while applying traction on umbilical cord
#3. oxytocin - 10 IU in 20 ml NS, inject into umbilical vein (contract uterus)
#4. if all fails - manual removal of placenta, D&C; hysterectomy as last resort
What is uterine inversion? Tx?
uterine inversion - medical emergency - most often from pulling too hard when delivering placenta, or due to abnormal implantation. medical emerg - risk of shock/sepsis (vasovagal response -> vasodilation + hypovolemia -> shock)
#1. ABC,give IV crystalloids (aqueous solutionsof mineral salts or other water-soluble molecules ex. NS), call anesthesia
#2. tocolytics to relax uterus (helps put it back)
#3. replace uterus, remove placenta very slowly (after replacement)
#4. oxytocin after replacing uterus (to control bleeding)
how is pre-existing hypertention (in pregnancy) defined?
how is it different from gestational hypertension?
hypertension in pregnancy = HIP
pre-existing: HTN >140/90 prior to 20 weeks gestation and > 7 weeks post partum
gestational: sBP > 140 or dBP>90 after 20 weeks GA in a normotensive woman
risks: primigravida, FHx, DM, renal problems, antiphospholipid syndrome (autoimmune, hypergoagulative due to antiphospholipid antibodies)
evaluation of hypertension in pregnancy?
- body weight
- blurry vision
- heme: bleeding, petechia (high pressure envir.)
- hepatic: RUQ pain/epigastric pain, nausea
- renal: change in output/colour
- fetal movement
- fetal growth (U/S)
- fetal HR (NST, Doppler)
- BPP - biophysical profile (U/S)
complications of hypertension in pregnancy? tests?
- liver and renal dysfunction
- seizure (tonic clonic most likely)
- abruptio placentae
- LV heart failure (high resistance!)
- DIC due to placental factors
- HELLP (hemolysis, elevated liver enzymes, low platelets)
- hemorrhagic stroke
- fetal: IUGR, prematurity, IUFD (fetal demise)
PTT, INR, fibrinogen, d-dimer etc - may need surgery, address DIC, HELLP
liver: ALT, AST, LDH, bili - r/o liver failure, HELLP
kidney: proteinuria, creatinine, uric acid, 24 hr urine - kidney failure
what is preeclampsia, how is it different from gestational hypertension/
preeclampsia = gestational hypertension + proteinuria or organ failure
management of hypertension in pregnancy?
labetalol (beta blocker) - 100-300 mg PO bid/tid L-à-ß-LOL (alpha/beta antagonist)
nifedipine (Ca++ channel blocker, heart protector + vasodilator) - 30-40 mg PO daily
alpha-methyldopa (sympatholytic, alpha 2 agonist) - 250-500 mg PO tid/qid
cannot do diuretics - reduces blood volume, thus blood flow to baby
cannot do ACE inhibitors - teratogenic
cannot do propanolol - teratogenic
management of preeclampsia?
depends on GA & treat of seizures
if stable -admit and follow until 34-36 weekes
if severe, stabilize and deliver
hydralazine (direct arterial vasodilator, short-acting) 5-10 mg IV bolus, labetalol 20-50 mg IV
MgSO4 for seizure prevention (but risk of toxicity)
what is eclampsia? management?
eclampsia - preeclampsia + convulsions or coma
often hyperreflexia present, typically tonic-clonc seizure (60 s +), symptoms of hypertension
#2: LLDP - maximize O2 to fetus
#3: O2 to treat hypoxemia post seizure
#4: antihypertensives: hydralazine/labetalol
#5. MgSO4 to protect from further seizures (if toxicity, calcium gluconate, stop MG)
#6: immediate delivery
urinary tract infections, etiology and clinical features?
- increased urinary stasis in pregnancy, more so due to progesterone
- most common complication of pregnancy
- must treat even if asymptomatic b/c of increased risk of cystitis, pyelonephritis and preterm labour
- symptoms of cystitis: urgency, dysuria, frequency
- symptoms in pyelonephritis: CVA tenderness, fever, flank pain
UTI in pregnancy, how do you investigate and manage?
Labs: urine C&S, urinalysis
if frequent infections, consider cystoscopy and renal fx tests
Tx: #1 - amoxicillin (250-500 mg PO q8h x 7 days)
or nitrofurantoin (100 mg PO bid x 7 days)
do urine samples monthly - recurrence common
if pyelonephritis suspected, hospitalize
When is the incidence of venous thromboembolism (VTE) the highest ? (T1/T2/T3...)
equal frequency in all three trimesters and postpartum
in pregnancy: increased factors (II, V, VII, VIII, IX, X, XII, fibrinogen), increased platelet aggregation, increased resistance to protein C, decrease in venous flow in lower extremity by T3, etc -> body prepares to coagulate in labour to avoid hemorrhage
most often in iliofemoral or calf veins, left leg
can lead to spontaneous fetal loss
venous thromboembolism, investigations? management?
Labs/tests: doppler for DVT
CXR and V/Q scan or spiral CT to r/o PE
no warfarin - teratogenic, unfractionated heparin and LMWH ok
#1 - do baseline CBC, including platelets and aPTT
#2 give bolus of 5,000 IU unfractionated heparin, than infusino of 30,000 IU/24 hrs, measure aPTT 6 h after bolus,maintain PTT @ 1.5-2x normal, repeat heparin dose q24 hrs once therapeutic level reached, beware of heparin-induced thrombocytopenia (3%)
#3can use compression stockings
#4 can consider aspirin with heparin for prophylaxis
Define antepartum hemorrhage?
antepartum hemorrhage = bleeding between 20-24 weeks gestation and delivery
Name 7+ causes of APH?
- placenta previa
- placental abruption
- succenturiate placenta
- uterine rupture
- vasa previa/velamentous insertion
- cervical polyps
- cervicitis (infection)
- vaginal lesions
- (not fibroids b/c they are uterine and cervix is closed)
What is velamenous umbilical cord?
Velamentous umbilical cord is characterized by membranous umbilical vessels at the placental insertion site (remainder of length normal). Membranous vessels can arise as aberrant branches of marginally insrted umbilical cord or can connect lobes of bilobed placenta or succenturiate lobe placenta. Due to lack of Wharton's jelly, these vessels are prone to compression and rupture, especially when at cervical os (ie. vasa previa)
1% singletons, 15% monochorionic twins
What is vasa previa? How do you manage it?
Vasa previa - unprotected fetal cord vessels passing over internal cervical os
1. Diagnose: TV U/S with colour Doppler
2. Corticosteroids at 28-32 weeks
3. Hospitalization at 30-32
4. C/S at 35 weeks with a higher LT incision. C/S early because want to prevent natural birth
if already in labour -> immediate delivery
Elective C/S - normal pregnancy - 39 weeks
placenta previa - 37 weeks
vasa previa - 35 weeks b/c fetal vessels very fragiled compared to mom
notice down by 2
Risk factors for uterine rupture? Prevalence?
previous C/S especially if classical, T incision or 1 layer closure, or if previous C/S with unknown incision, trauma
no cervidil - known to increase incidence
oxytocin augmentation is controversial
classical vertical scar - 10% risk of rupture
LT scar - 0.5% risk (1 in 200), can try VBAC
if unknown C/S - repeat rather than deliver vaginally (skin incision does not always mimic uterine incision)
Presentation of uterine rupture?
- unexplained vaginal bleeding -> hypovolemia, shock (bleeding can also be concealed)
- severe abdominal pain
- sudden cessation of uterine contractions
- "tearing" sensation
- fetal bradycardia or nonreasuring strip
- movement of presenting part higher than before
Immediate laparotomy and delivery, may require hysterectomy
Define placental abruption?
Premature separation of normally implanted placenta from the uterine wall before the delivery of the baby
Resulting decidual hemorrhage can cause even more bleeding and shearing
Symptoms suggesting abrupted placenta?
1% , stillbirth 1 in 830
abdominal pain + vaginal bleeding
revealed in 80%, concealed in 20%
uterine hypertonicity (body tries to deliver b/c at risk)
risks: hypovolemia secondary to blood loss
adult respiratory distress syndrome
multisystem organ failure
tachy, nonreassuring fetal heart rate (detached portion unable to exchange gasses and nutrients)
What are common risk factors for placental separation?
- hypertension (pre-existing or gestational)
- smoking (not EtOH)
- trauma esp. shearing trauma (MVA)
- crowding: high parity or polyhydramnios
- sudden decompression (PROM, PPROM)
previous Hx of placental abruption
What are management steps for placental abruption?
- Hx and PEx - no vaginal exam until previa ruled out
- continuous fetal monitoring (if distressed C/S if not, can try for vaginal)
- U/S for fetal distress "not really clinically useful except to r/o previa" b/c of bleeding
- CBC, crossmatch, coag profile (r/o anemia, DIC, prepare for transfusion) -> can then correct shock by IV fluids, RBCs, O2
- Management expectant - if no fetal distress - can try for normal labour, if distress - C/S
- "manage expectantly b/c clots from abrupted placenta tend to irritate uterus, so patients go into labour really quickly"
To deliver vaginally:
monitor maternal vital signs -r/o ABC + multisystem organ failure + adult resp.distress syndrome
monitor maternal urine output - r/o hypovolemia+shock+renal damage
fetal heart rate monitoring - ABC
CBC and coag profile serially - r/o DIC
Things we're looking for on mom's physical in vaginal bleed?
presence of contractions
is bleeding active? colour? amount?
What is DIC? What would be expected blood work results?
DIC = disseminated intravascular coagulation - systemic process resulting in both thrombosis and subsequent hemorrhage.
1. exposure of blood to procoagulants, such as tissue factor (extrinsic pathway) and cancer procoagulants
2. fibrin clot
4. clotting factors depleted
5. hemorrhage, end-organ damage
DIC is a complication of underlying illness - in 1% of hospital admissions, support with platelets and clotting factors. Tx the underlying disease
~ low platelets (used up)
~ low fibrinogen (used up)
~ increased aPTT and INR (clotting factors used up)
~ d-dimers present (fibrin degradation product)
Name 3+ maternal complications and 1+ fetal complication of placental abruption?
hemorrhage -> shock, death
multisystem organ failure
ARDS - adult resp distress syndrome = widespread inflammation in the lungs. While ARDS may be triggered by a trauma or lung infection, it is usually the result of sepsis. ARDS is a disease of alveoli that leads to decreased exchange of oxygen and carbon dioxide (gas exchange). ARDS is associated with several pathologic changes: the release of inflammatory chemicals, breakdown of the cells lining the lung's blood vessels, surfactant loss leading to increased surface tension in the lung, fluid accumulation in the lung, and excessive fibrous connective tissue formation. Mortality 20-50%
also Sheehan's, Couvelaire uterus (bruised)
intrauterine fetal demise